A new idea for hospice

The dual coverage of hospice care for nursing home residents is a complex and confusing arrangement enacted by Congress in 1989 to ensure that the Medicare hospice benefit and hospice's specialized, compassionate support for patients nearing the end of their lives could be accessed by residents of long-term care facilities the same as for those living in their own homes.

Essentially, Medicare (as well as Medicaid) patients who qualify for and consent to hospice care and have their long-term care covered by Medicaid can enroll on the hospice benefit, with the hospice provider assuming responsibility for managing their care and receiving two payments from the government.

One of those payments is for interdisciplinary professional management of the patient's terminal condition at Medicare's usual rate and the other is for room and board at 95% of the prevailing Medicaid nursing home rate for that patient's bed—which is then passed on by the hospice to the nursing home for providing room-and-board care and related services.

This dual coverage arrangement requires a contract between the Medicare-certified hospice and the nursing home. Such care answers to two separate regulatory systems—for hospice and for the nursing facility—that aren't always well coordinated and to two philosophies of care that can sometimes be at odds.

As U.S. hospices come under growing scrutiny from an alphabet soup of Medicare fraud-and-abuse watchdog agencies, the hospice benefit for nursing home residents remains a particular sore point for the government. Some have questioned whether this complex coverage mechanism is really the best way to pay for end-of-life care in facilities, or if it gives the government full value for the outlay.

Alternative arrangements

A recent article in Health Affairs by Haiden Huskamp and colleagues from Harvard Medical School [July 29, 2010, edition] casts an interesting light on these issues. Although their paper was developed to better align end-of-life care benefits with nursing home residents' needs—not to address fraud-and-abuse concerns—it argues that the one-size-fits-all model of hospice as currently defined by Medicare is not a good fit for the long-term care setting.

The authors say it can be hard to determine a clear prognosis of six months or less, as the hospice benefit requires, or a clear hospice-admitting diagnosis for residents who are likely to have multiple chronic conditions. They cite a body of research documenting inadequate care for terminally ill nursing home residents overall in areas such as pain and symptom management and family dissatisfaction. They also note that only a minority of dying nursing home residents ever receives hospice care.

And so they propose an alternative approach, basically a new Medicare end-of-life care benefit tailored to elderly nursing home residents. It would pay nursing homes an additional fee to provide end-of-life care to residents who meet an end-of-life threshold of need, giving them the option of contracting with hospices for consultation on end-of-life care. Unlike the current hospice benefit, this new benefit would not require recipients to forgo curative care.

The nursing home, rather than the hospice, would become the locus of responsibility for the patient's end-of-life care, with new resources and flexibility to provide integrated services to all nursing home residents nearing the end of life, but with accountability to new end-of-life care quality measures that would need to be developed. The authors do not specify the form of such a benefit, suggesting that it could be a per-diem supplement or part of bundled payment for post-acute care.

A companion article by Dr. Diane Meier, director of the Center to Advance Palliative Care, and colleagues essentially agrees but argues that the real answer is palliative care—a service similar to hospice in goals and methods but without its prerequisite for a quantifiable terminal prognosis. Palliative care consultation services have become common in hospitals across the country, helping hospitalized, seriously ill patients clarify their values and goals for treatment and addressing their symptom management needs. Meier proposes making palliative care the default type of care for every resident of a long-term care facility who has dementia, with staff training, regulation and payment modified accordingly.

These two articles, with far-reaching proposals in an influential health policy journal, received little attention in the hospice or long-term care industries. But they were noticed by the government, to judge from an April 30 meeting of policy makers and researchers convened by the Office of the Assistant Secretary for Planning and Evaluation in the Centers for Medicare & Medicaid Services and the National Institute on Aging to discuss hospice/nursing facility interaction and issues raised in the articles.

The growth of hospice

In recent years CMS, the Office of the Inspector General and the Medicare Payment Advisory Commission (MedPAC) have all expressed concerns about the hospice benefit in the nursing home. This sector has proliferated as hospice was growing into a $12 billion industry under Medicare.

In two reports issued last September, OIG found that nursing home residents represented 31% of hospice patients covered by Medicare in 2006, while technical violations of hospice billing requirements were rife. Nursing home residents are also more likely to be among the long-stay hospice patients who worry CMS and MedPAC.

At the same time, a body of evidence by Susan Miller and colleagues at the Center for Gerontology and Health Care Research at Brown University shows that the presence of hospice in nursing homes improves the quality of care, not just for the hospice-enrolled resident, but for other residents of the facility, as well. Hospice involvement reduces overall Medicare expenditures on nursing home residents in the last month of life and their rates of hospitalization.

If either Huskamp's or Meier's proposal were adopted—and there is no reason to think that either is on a policy fast track at this time—the result for the hospice industry could be catastrophic, with billions in revenues at stake. Hospices whose current business model targets long-term care facilities might be out of business, while others would see significant drops in census and the need to establish themselves as end-of-life care consultants to nursing homes.

Hospice advocacy groups have signaled their intent to preserve the current hospice benefit for nursing home residents. However, in an era of heightened scrutiny, hospices are challenged to both ensure and demonstrate the quality of their care in the nursing home, enrolling only eligible patients on Medicare and providing them with a level of services equivalent to what hospice patients living at home receive.

Based on anecdotal reports I have heard from hospice consultants, the quality of such care is variable, and in some cases may not be up to the standard we would want for our own parents if they were terminally ill and residing in a nursing home.I share the concerns of government watchdogs that these expectations too often are not being met.

A new responsibility

But are nursing homes ready to take on the end-of-life care needs of their residents, as envisioned by Huskamp and others? Are they able to manage the pain of terminal illness, or tend to the grief of their residents' family survivors and long-time nursing home staff, as hospices routinely do? Is this something nursing homes would even want to do, given their focus on rehabilitation, maximizing function, ambulation and nutrition?

Nursing homes today are more likely than ever to be asked to sign contracts with Medicare-certified hospices and to refer appropriate residents for hospice care—especially in communities where dozens of hospices compete for their business. But they should be aware that this benefit is in the sights of government watchdogs.

Nursing homes asked to contract with a hospice should ask specific questions about the quality of the hospice's services, the frequency of its visits, the team's accessibility for after-hours medical crises and the like.

Models of successful hospice-nursing home partnerships have been documented, while new Medicare conditions of participation for hospices, issued in June of 2008, address in greater detail essential care planning processes and the care of patients residing in nursing homes. New nursing home standards said to be friendlier to patients' end-of-life care needs are in the works.

Could such regulations, more scrupulously enforced, help to address the concerns of policy makers and support the preservation of a controversial benefit proven to enhance the quality of life of nursing home residents at the end of their lives?

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Larry Beresford is an Oakland, CA-based freelance medical writer and editor specializing in hospice, palliative and end-of-life care. His end-of-life care blog can be viewed at growthhouse.typepad.com/larry_beresford.

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